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Canadian Journal of Anaesthesia =... Apr 2024Rib fracture(s) is a common and painful injury often associated with significant morbidity (e.g., respiratory complications) and high mortality rates, especially in the... (Review)
Review
PURPOSE
Rib fracture(s) is a common and painful injury often associated with significant morbidity (e.g., respiratory complications) and high mortality rates, especially in the elderly. Risk stratification and prompt implementation of analgesic pathways using a multimodal analgesia approach comprise a primary endpoint of care to reduce morbidity and mortality associated with rib fractures. This narrative review aims to describe the most recent evidence and care pathways currently available, including risk stratification tools and pharmacologic and regional analgesic blocks frequently used as part of the broadly recommended multimodal analgesic approach.
SOURCE
Available literature was searched using PubMed and Embase databases for each topic addressed herein and reviewed by content experts.
PRINCIPAL FINDINGS
Four risk stratification tools were identified, with the Study of the Management of Blunt Chest Wall Trauma score as most predictive. Current evidence on pharmacologic (i.e., acetaminophen, nonsteroidal anti-inflammatory drugs, gabapentinoids, ketamine, lidocaine, and dexmedetomidine) and regional analgesia (i.e., thoracic epidural analgesia, thoracic paravertebral block, erector spinae plane block, and serratus anterior plane block) techniques was reviewed, as was the pathophysiology of rib fracture(s) and its associated complications, including the development of chronic pain and disabilities.
CONCLUSION
Rib fracture(s) continues to be a serious diagnosis, with high rates of mortality, development of chronic pain, and disability. A multidisciplinary approach to management, combined with appropriate analgesia and adherence to care bundles/protocols, has been shown to decrease morbidity and mortality. Most of the risk-stratifying care pathways identified perform poorly in predicting mortality and complications after rib fracture(s).
Topics: Humans; Aged; Rib Fractures; Chronic Pain; Pain Management; Analgesia; Analgesics; Analgesia, Epidural
PubMed: 38459368
DOI: 10.1007/s12630-024-02725-1 -
European Journal of Orthopaedic Surgery... Aug 2023The primary aim was to describe the population characteristics of patients with combined scapula and rib fractures and outcomes associated with different treatment...
PURPOSE
The primary aim was to describe the population characteristics of patients with combined scapula and rib fractures and outcomes associated with different treatment strategies.
METHODS
All adult (≥ 18 years) patients with concurrent ipsilateral scapula and rib fractures admitted to the study hospital between 1st January 2010 and 31st June 2021 were retrospectively reviewed.
RESULTS
A total of 223 patients were admitted with concurrent ipsilateral rib and scapula fractures. A total of 160 patients (72%) were treated conservatively, 63 patients (28%) operatively. Among operatively treated patients, 32 (51%) underwent rib fixation (RF) only, 24 (38%) underwent scapula fixation (SF) only, and seven patients (11%) underwent combined fixation of scapula and ribs (SRF). In general, more severely injured patients were treated with more extensive surgery. RF patients had a median hospital length of stay of 16 days, the SF patients 11 days and SRF patients 18 days. There were no significant differences in complications (pneumonia, recurrent pneumothorax and revision surgery) between groups.
CONCLUSION
Injury severity resulted in different treatment modalities. As a result, different patient characteristics between treatment groups were observed, which makes direct comparison between treatment modalities impossible. All treatment modalities seem feasible; however, the additional value of both rib and scapula fixation has yet to be proven in large multicentre studies.
Topics: Adult; Humans; Rib Fractures; Retrospective Studies; Flail Chest; Thoracic Injuries; Fracture Fixation, Internal; Treatment Outcome; Length of Stay
PubMed: 36401000
DOI: 10.1007/s00590-022-03437-2 -
World Neurosurgery Dec 2023There are several approaches used for surgical treatment of neurogenic thoracic outlet syndrome (n-TOS). The posterior upper rib excision and decompression technique is...
BACKGROUND
There are several approaches used for surgical treatment of neurogenic thoracic outlet syndrome (n-TOS). The posterior upper rib excision and decompression technique is a novel technique that was developed and used by the author for the past 8 years. The purpose of this paper is to report clinical outcomes of patients treated with this approach.
METHODS
All patients with n-TOS operated by single surgeon from 2015 to 2023 were retrospectively analyzed. Demographic, clinical, radiologic, surgical, and postoperative data were collected and reported with emphasis on efficacy and complications. The surgical success was evaluated subjectively as excellent, good, fair, poor, and bad. Radiologic data were analyzed to assess the extent of accessory/first rib removal.
RESULTS
Eighty procedures were performed in 61 patients with a mean follow-up of 1153 (87-3048) days. The majority (60.7%) of patients were women, with 39.3% being men. In 11 cases (18%) causative factor was bone abnormality. Two patients were previously operated at another centers (3.3%). Total mean subjective improvement rate was 91.5%. More than half (55) of the patients reported "excellent" (>75%) and 6 "good" improvements (50%-75%); no fair, poor, and worse outcomes were reported. Patients reporting "good" outcome had statistically significant shorter follow-ups than the "excellent" group (P < 0.001). Complications included pleural opening, Horner syndrome, and apical hematoma, none of which were permanent.
CONCLUSIONS
The posterior upper rib excision and decompression approach provides excellent clinical outcomes in patients with n-TOS. It allows better intraoperative visualization and removal of the first rib and full decompression of the neurovascular bundle.
Topics: Humans; Male; Female; Retrospective Studies; Treatment Outcome; Decompression, Surgical; Thoracic Outlet Syndrome; Ribs
PubMed: 37813334
DOI: 10.1016/j.wneu.2023.10.017 -
Journal of Clinical Anesthesia Dec 2023Surgical stabilization of rib fractures (SSRF) has become an increasingly common management strategy for traumatic rib fractures. Although historically managed with... (Review)
Review
Surgical stabilization of rib fractures (SSRF) has become an increasingly common management strategy for traumatic rib fractures. Although historically managed with supportive care, patients with multiple rib fractures and flail chest increasingly undergo SSRF, and so the anesthesiologist must be well-versed in the perioperative management and pain control for these patients, as controlling pain in this population is associated with decreased length of stay and improved outcomes. There are multiple modalities that can be used for both pain control and as part of the anesthetic plan in patients undergoing SSRF. This narrative review provides a comprehensive summary of anesthetic considerations for surgical rib fracture patients, covering the preoperative, intraoperative, and postoperative periods. We describe an approach to the assessment of high-risk patients, analgesic and anesthetic techniques including emerging techniques within locoregional anesthesia, ventilation strategies, and potential complications. This review also identifies areas where additional research is needed to ensure optimal anesthetic management for patients undergoing SSRF.
Topics: Humans; Rib Fractures; Fracture Fixation; Fracture Fixation, Internal; Length of Stay; Anesthetics; Pain; Retrospective Studies
PubMed: 37797395
DOI: 10.1016/j.jclinane.2023.111275 -
The Surgical Clinics of North America Dec 2023In this review article, we aim to provide an overview of common and uncommon general surgery thoracic emergencies as well as basic thoracic anatomy, common diagnostic... (Review)
Review
In this review article, we aim to provide an overview of common and uncommon general surgery thoracic emergencies as well as basic thoracic anatomy, common diagnostic tests, and operative positioning and access considerations. We also describe specific thoracic procedures. We hope that this article simplifies some of the challenges associated with the management of thoracic emergencies.
Topics: Humans; Thoracic Injuries; Emergencies; Wounds, Nonpenetrating; Surgeons; Rib Fractures
PubMed: 37838457
DOI: 10.1016/j.suc.2023.07.005 -
Optics Express Dec 2023Waveguiding across the visible spectrum in an unmodified bulk CMOS chip is reported. The chip is fabricated in a standard CMOS process, and a simple wet etch removes...
Waveguiding across the visible spectrum in an unmodified bulk CMOS chip is reported. The chip is fabricated in a standard CMOS process, and a simple wet etch removes metal in predetermined locations to expose glass rib waveguides. A modified Euler bend is introduced to improve bend radii by nearly an order of magnitude in the rib waveguides, and upper-bound losses are measured at visible wavelengths. These losses range from 6.2 dB/cm at 450 nm to 3.2 dB/cm at 650 nm and represent the lowest losses reported at visible wavelengths in unmodified bulk CMOS.
PubMed: 38087612
DOI: 10.1364/OE.502252 -
Unfallchirurgie (Heidelberg, Germany) Mar 2024Traumatic injuries of the thorax can entail thoracic wall instability (flail chest), which can affect both the shape of the thorax and the mechanics of respiration;... (Review)
Review
Traumatic injuries of the thorax can entail thoracic wall instability (flail chest), which can affect both the shape of the thorax and the mechanics of respiration; however, so far little is known about the biomechanics of the unstable thoracic wall and the optimal surgical fixation. This review article summarizes the current state of research regarding experimental models and previous findings. The thoracic wall is primarily burdened by complex muscle and compression forces during respiration and the mechanical coupling to spinal movement. Previous experimental models focused on the burden caused by respiration, but are mostly not validated, barely established, and severely limited with respect to the simulation of physiologically occurring forces. Nevertheless, previous results suggested that osteosynthesis of an unstable thoracic wall is essential from a biomechanical point of view to restore the native respiratory mechanics, thoracic shape and spinal stability. Moreover, in vitro studies also showed better stabilizing properties of plate osteosynthesis compared to intramedullary splints, wires or screws. The optimum number and selection of ribs to be fixated for the different types of thoracic wall instability is still unknown from a biomechanical perspective. Future biomechanical investigations should simulate respiratory and spinal movement by means of validated models.
Topics: Humans; Thoracic Wall; Rib Fractures; Thoracic Injuries; Biomechanical Phenomena; Flail Chest
PubMed: 37964040
DOI: 10.1007/s00113-023-01389-8 -
Chirurgie (Heidelberg, Germany) Sep 2023Thoracic trauma is associated with a high morbidity and mortality. Assessing the risk for complications is essential for planning the further treatment strategies and...
BACKGROUND
Thoracic trauma is associated with a high morbidity and mortality. Assessing the risk for complications is essential for planning the further treatment strategies and managing resources in thoracic trauma.
OBJECTIVE
The aim of the study was to analyze concomitant injuries in unilateral and bilateral rib fractures and pulmonary contusions and evaluate differences in complication rates between the two.
MATERIAL AND METHODS
In a retrospective study, data from all patients diagnosed with thoracic trauma at a level I trauma center were analyzed. Bivariate and multivariate analysis were used to examine an association of unilateral or bilateral rib fractures, serial rib fractures, and pulmonary contusions with multiple injuries and outcomes. In addition, multivariate regression analysis was utilized to determine the impact of age, gender and additional injuries on outcome.
RESULTS
A total of 714 patients were included in the analysis. The mean Injury Severity Score (ISS) was 19. Patients with an additional thoracic spine injury had a significantly higher incidence of bilateral rib fractures. Pulmonary contusions were associated with younger age. Abdominal injuries were predictors for bilateral pulmonary contusions. Complications occurred in 36% of the patients. Bilateral injuries increased the complication rate up to 70%. Pelvic and abdominal injuries as well as the need for a chest drain were significant risk factors for complications. The mortality rate was 10%, with higher age, head and pelvic injuries as predictors.
CONCLUSION
Patients with bilateral chest trauma had an increased incidence of complications and a higher mortality rate. Bilateral injuries and significant risk factors must therefore be considered. Injury of the thoracic spine should be excluded in those patients.
Topics: Humans; Rib Fractures; Retrospective Studies; Wounds, Nonpenetrating; Thoracic Injuries; Lung Injury; Contusions; Abdominal Injuries
PubMed: 37268786
DOI: 10.1007/s00104-023-01891-0 -
Spine Deformity Nov 2023The Law Of Diminishing Returns (LODR) has been demonstrated for traditional growing rods, but there is conflicting data regarding the lengthening behavior of...
PURPOSE
The Law Of Diminishing Returns (LODR) has been demonstrated for traditional growing rods, but there is conflicting data regarding the lengthening behavior of Magnetically Controlled Growing Rods (MCGR). This study examines a cohort of patients with early-onset scoliosis (EOS) with rib-to-spine or rib-to-pelvis-based MCGR implants to determine if they demonstrate the LODR, and if there are differences in lengthening behaviors between the groups.
METHODS
A prospectively collected multicenter EOS registry was queried for patients with MCGR with a minimum 2-year follow-up. Patients with rib-based proximal anchors and either spine- or pelvis-based distal anchors were included. Patients with non-MCGR, unilateral constructs, < 3 lengthenings, or missing > 25% datapoints were excluded. Patients were further divided into Primary-MCGR (pMCGR) and Secondary-MCGR (sMCGR).
RESULTS
43 rib-to-spine and 31 rib-to-pelvis MCGR patients were included. There was no difference in pre-implantation, post-implantation and pre-definitive procedure T1-T12 height, T1-S1 height, and major Cobb angles between the groups (p > 0.05). Sub-analysis was performed on 41 pMCGR and 19 sMCGR rib-to-spine patients, and 31 pMCGR and 17 sMCGR rib-to-pelvis patients. There is a decrease in rod lengthenings achieved at subsequent lengthenings for each group: rib-to-spine pMCGR (rho = 0.979, p < 0.001), rib-to-spine sMCGR (rho = 0.855, p = 0.002), rib-to-pelvis pMCGR (rho = 0.568, p = 0.027), and rib-to-pelvis sMCGR (rho = 0.817, p = 0.007). Rib-to-spine pMCGR had diminished lengthening over time for idiopathic, neuromuscular, and syndromic patients (p < 0.05), with no differences between the groups (p > 0.05). Rib-to-pelvis pMCGR neuromuscular patients had decreased lengthening over time (p = 0.01), but syndromic patients had preserved lengthening over time (p = 0.65).
CONCLUSION
Rib-to-spine and rib-to-pelvis pMCGR and sMCGR demonstrate diminished ability to lengthen over subsequent lengthenings.
PubMed: 37450222
DOI: 10.1007/s43390-023-00718-6